What Is an Inquest?

An inquest is a judicial inquiry into the circumstances of a death. It is not a trial. There are no parties in the adversarial sense: no prosecution and no defence. The purpose is fact-finding. The coroner investigates and the inquest seeks to establish four things: who the deceased was, when they died, where they died, and how they came by their death. This is set out in section 5 of the Coroners and Justice Act 2009.

An inquest is inquisitorial, not adversarial. The coroner controls the proceedings: calling witnesses, determining the scope of the inquiry, and directing what evidence is heard. There is no prosecution seeking a conviction and no defence contesting a charge. Witnesses are questioned by the coroner, and interested persons (or their legal representatives) may ask questions with the coroner's permission, but the proceedings are fundamentally different from a criminal trial.

The Role of the Coroner

A coroner is an independent judicial officer. Coroners are appointed by the relevant local authority but act independently of both local and central government. They must be legally qualified (a solicitor or barrister of at least five years' standing, or a Fellow of the Chartered Institute of Legal Executives with five years' experience). Senior coroners, area coroners, and assistant coroners serve in coroner areas across England and Wales.

The Chief Coroner, a judge of the High Court, provides national leadership, issues guidance, and monitors the consistency and quality of coroner services. The office of Chief Coroner was established by the Coroners and Justice Act 2009 and is supported by the Chief Coroner's office within the judiciary.

When Must an Inquest Be Held?

Under section 1(2) of the Coroners and Justice Act 2009, a coroner has a duty to investigate a death where the coroner has reason to suspect that:

• the deceased died a violent or unnatural death
• the cause of death is unknown
• the deceased died while in custody or otherwise in state detention

Where the coroner conducts an investigation, an inquest must be held as part of that investigation (s.6). Not every death reported to a coroner results in a full inquest: many are resolved following a preliminary investigation or post-mortem examination that establishes a natural cause of death. An inquest is required where the cause remains uncertain after investigation, or where the circumstances of death engage the criteria above.

Deaths in custody or state detention always require an inquest with a jury (s.7(2)(a)). This includes deaths in prison, police custody, immigration detention, and psychiatric hospitals where the person was detained under the Mental Health Act 1983.

Conclusions: Short-Form and Narrative

At the end of an inquest, the coroner (or jury, where applicable) records a conclusion. The term "conclusion" replaced the older term "verdict" under the 2009 Act. The conclusion answers the statutory questions: who, when, where, and how.

The available short-form conclusions include:

• Natural causes
• Accident or misadventure
• Suicide
• Unlawful killing
• Lawful killing
• Industrial disease
• Drug-related death
• Alcohol-related death
• Road traffic collision
• Stillbirth
• Open conclusion (where the evidence does not permit any other conclusion)

Alternatively, the coroner or jury may return a narrative conclusion: a brief factual statement setting out the circumstances of the death in the coroner's or jury's own words. Narrative conclusions are commonly used in complex or sensitive cases where the circumstances cannot be adequately captured by a short-form conclusion alone. A narrative conclusion may be combined with a short-form conclusion.

The Standard of Proof

The standard of proof at an inquest varies depending on the conclusion:

• Unlawful killing and suicide: these conclusions must be proved to the criminal standard, that is, beyond reasonable doubt (sometimes expressed as "so that you are sure").
• All other conclusions: the civil standard applies, that is, the balance of probabilities (more likely than not).

This distinction is important. The higher standard for unlawful killing and suicide reflects the gravity of those conclusions and their potential implications. A jury that is not satisfied to the criminal standard that a death was an unlawful killing may nonetheless record a narrative conclusion that sets out the relevant facts.

Article 2 ECHR: Enhanced Inquests

Article 2 of the European Convention on Human Rights (given effect in domestic law by the Human Rights Act 1998) protects the right to life. It imposes a positive obligation on the state to protect life and, where a death may have resulted from state action or a failure by the state to protect life, a procedural obligation to conduct an effective, independent investigation.

Where Article 2 is engaged, the inquest takes an enhanced form. The scope of the inquiry widens: instead of asking merely "how" the deceased died (the means by which death occurred), the coroner must also ask "in what circumstances" the death occurred. This broader inquiry allows examination of systemic failures, regulatory shortcomings, and whether the state discharged its duty to protect life.

Article 2 is typically engaged in deaths in state custody (prisons, police custody, immigration detention, psychiatric hospitals), deaths resulting from the actions of state agents (including police shootings), and deaths where state services arguably failed to protect a known risk to life. In Article 2 inquests, the jury (where present) may make findings about systemic failures.

Interested Persons

An interested person is someone who has a particular interest in the inquest and is entitled to participate in the proceedings. Section 47 of the Coroners and Justice Act 2009 defines who may be an interested person. The list includes:

• The spouse, civil partner, partner, parent, child, brother, sister, grandparent, grandchild, or friend of the deceased
• The personal representative of the deceased
• A beneficiary under a policy of insurance issued on the life of the deceased
• Any person whose act or omission may have caused or contributed to the death
• A chief officer of police (in cases involving police action)
• A body or authority with responsibility for the place where the death occurred (such as a prison governor, hospital trust, or care home operator)
• Any other person the coroner considers has a sufficient interest

Interested persons have the right to receive disclosure of documents relevant to the inquest, to attend the inquest hearing, to examine witnesses (with the coroner's permission), and to make submissions on the conclusion. The coroner has discretion to determine who qualifies as an interested person.

The Difference Between an Inquest and a Trial

It is essential to understand what an inquest is not. An inquest is not a criminal trial: no one is on trial, no criminal charge is determined, and a conclusion of unlawful killing does not of itself result in criminal proceedings (though it may prompt a police investigation or prosecution).

An inquest is not a civil claim: it does not determine liability or award damages. The findings of an inquest cannot be used as evidence in subsequent civil or criminal proceedings to establish liability, though the factual findings may be relevant.

The prohibition on determining criminal or civil liability is set out in section 10(2) of the Coroners and Justice Act 2009: a determination may not be framed in such a way as to appear to determine any question of criminal liability on the part of a named person, or any question of civil liability.

Legal Representation at Inquests

There is no automatic right to legal aid for inquests. The Legal Aid, Sentencing and Punishment of Offenders Act 2012 (LASPO) removed most inquests from the scope of legal aid. However, exceptional case funding may be available under section 10 of LASPO where the failure to provide legal aid would breach the individual's Convention rights (particularly Article 2). In practice, this means that bereaved families in Article 2 inquests may be able to obtain legal aid, but many families in non-Article 2 inquests must fund their own representation or attend without a lawyer.

Interested persons may instruct a solicitor or barrister to represent them at the inquest. Pro bono representation is sometimes available through charities such as INQUEST or through barristers acting on a pro bono basis.

For a step-by-step guide to the inquest process, see our Inquest Process guide. For the legislation governing inquests, see Key Legislation.

This page is for general information only and does not constitute legal advice. If you have been bereaved and an inquest is being held, please consider seeking legal advice from a solicitor experienced in inquest work.